20 Appropriate Use of Single-Chamber Ventricular Pacing in a Large DGH – Are we Selecting the Right Patients?

Abstract

Introduction In the UK, significant numbers of patients are treated with single-chamber ventricular pacing (VVI/R) for bradycardia indications, despite being in sinus rhythm. We evaluated the profile and outcomes of such patients at our institution. We demonstrate that when this mode of pacing is selectively chosen it is effective and well tolerated. Methods Electronic records at Ipswich Hospital NHS Trust from January 2010 to October 2013 were reviewed to identify the total number of new implants, and the underlying rhythm in those receiving VVI/Rs. Records of patients not in chronic atrial fibrillation (AF) were reviewed further to identify reasons for VVI/R implant, whether they developed AF, experienced symptoms of pacemaker syndrome or required an upgrade. Results Table 1 outlines the number and type of new pacemakers implanted, as well as the compliance with NICE guidelines. The three patients falling outside of NICE guidelines were intended to have DDD/R implants but operators were unable to position an atrial lead successfully. Of the remaining 38 patients in sinus rhythm, the choice of pacing mode was influenced by a combination of frailty, limited mobility, age and comorbidities (see Figure 1). The most common indication was atrioventricular block, the mean patient age was 91 (range 80 to 101), and the mean follow up period was 10 months (max. 43) with an expected drop out due to mortality. In those selected for VVI/R there were two new instances of paroxysmal AF and one patient experienced dizziness, which may have been attributable to her pacemaker (one possible mild pacemaker syndrome). In those with failed atrial lead placement, one patient with a prior history of paroxysmal AF developed persistent AF. No patients required a pacemaker upgrade (see Table 2). Conclusions In our institution, 14.6% of the patients treated with VVI/Rs were in sinus rhythm, which extrapolates to approximately 1,500 patients across England and Wales each year. 70% of the patients we selected for such a treatment strategy were over 90 years of age, and all had multiple additional influential factors. We demonstrate a low incidence of further symptoms, pacemaker syndrome and atrial fibrillation. In appropriately selected patients, simple VVI pacing is effective and well tolerated.